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DEPARTMENT OF PUBLIC WORKS <br />DIVISION OF ENGINEERING <br />QvmbtljQbslJnqspwfnfout <br />229.1674 <br />Project Number: _______________ Project Name: __________________________ Change Order #: ____ <br />302103131 <br />DATE INITIATED:BPW DATE: <br />Brief Summary of Change Order; (Construction Change, Alternative, Substitution, Differing Instructions, Out of Scope, Etc.). <br />2/Jotubmmifbuubqf0jotvmbujpopoxbufsnbjojouifsftusppn.%3-375/11 <br />3/Sfnpwfdpodsfufcvsjfevoefsqspqptfesfufoujpoqpoe.%2-777/61 <br />4/Izesp.tffebeejujpobm2-255TZT.%21-6::/11 <br />5/Sfmpdbuf4pvudspqqjohcpvmefstgspnqmbzhspvoe.%2-138/11 <br />Attachments: (List documents support changerequired) <br />Dpousbdupsdptuftujnbuft/ <br />QDS$4/ <br />26-667/61 <br />Amount of Increase / Decrease: $____________________ <br />Categories (Pick One): <br />3-395/11 <br />ScopeofWork <br />Previously approved Change Order(s): $___________________ <br />DifferingSiteConditions,ChangedConditions <br />2/88 <br />Current Percent of Change: ____________________ % <br />ConflictedSpecificationsandDrawings <br />FailedMaterials <br />9:7-637/86 <br />New Total Amount: $____________________ <br />Error <br />Omission <br />3/14 <br />Total Percent of Change: ____________________ % <br />FinalQuantityAdjustment <br />______________________ <br />563.2212.563/42.17 <br />Funding Secured From: __________________________ <br />(filled out by PM) <br />RECOMMENDEDBY: <br />Ejhjubmmz!tjhofe!cz!Hsfh!NdHpxbo! <br />Hsfh!NdHpxbo <br />HsfhNdHpxbo5.3.31 <br />Ebuf;!3131/15/13!24;16;28!.15(11( <br />Project Inspector (Print Name)(Signature)(Date) <br />REVIEWED BY: <br />Ejhjubmmz!tjhofe!cz!Upz!Wjmmb! <br />Upz!Wjmmb <br />UpzWjmmb15013031 <br />Ebuf;!3131/15/13!24;69;26!.15(11( <br />Construction Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />Ejhjubmmz!tjhofe!cz!Lzmf!X/!Tjmwfvt! <br />EO;!do>Lzmf!X/!Tjmwfvt-!p>Djuz!pg!Tpvui!Cfoe-!pv-! <br />fnbjm>ltjmwfvtAtpvuicfoejo/hpw-!d>VT! <br />Lzmf!X/!Tjmwfvt <br />LzmfX/Tjmwfvt50703131 <br />Ebuf;!3131/15/17!25;26;42!.15(11( <br />Engineering Project Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />Ejhjubmmz!tjhofe!cz!Lbsb!Cpzmft! <br />Lbsb!Cpzmft <br />LbsbCpzmft50703131 <br />Ebuf;!3131/15/17!26;17;62!.15(11( <br />City Engineer (Print Name)(Signature)(Date) <br /> <br />